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HOSPITAL CLAIM OF Lli)i
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5'rA'l'E 01>' FLORIDA
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COUN1'Y 01" 5'1'. LUCIE)
JOHN };'. '"r.{MEH, JR.., !lit the duly au thor1 y.ed aeon t of
GOOD 3MlAHI'rAN HOs'l'ri'AL ASSOC TATl ON, opero.t Ing tho GOOD SAl:A~nT;'J~
HOJPITAL at 'Jost Pa.l~ Beach, :liar Idu, bo1nt: duly tn401'I\, deposes
and Bays t.hat:
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1. F'LOH.EIICE KA'{E, whose addr6ss 0.8 :3hoWtl on t.ho hospit..
81 reoorda 1s 4511 Juanita Avenue, Pt. PIerco, Plorldn, was
adro!. t ted 6.5 a pa tlcnt 1 n such Honpltal on J anua1')' 29, 1962 and
d1schurged on February 11, 1962.
2. The Hoapltnlclalma SIX Hm;:ml.~D SE'/Eli DULLAHS and
FIF>TY CEN~ (~607.50) in duo 1,t for care, troatmont, and mn1nton-
lUtCS or aald pa t10nt during tho aforeaatd period of ti rl3e..
To tho bost lmowlodgf) of tho undor~l1cnod, tho plttlon ,
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(or hor ~ ral Topre Blltl to.. tl ve) ol(\lms the follOll1nL P orsonn,
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firMS,
or corpQl'ut1una, at tho addr6Bo68 shown, .are l!aulo tHi acoount of
tho 111n038 or injurios wh ich lus.do tho (lfort;II~1d hOBpltall~Rtion
nOCe8B(iry~
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Adflroos
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Barna Pae1dng HOU80
Pt. _ Piorce, /'101'\do.
Bar trord In3uranoo Co.
~ ( Hr. !J.m 63. Cla1m Agt)
Guaranty HIdE., West Palm v05ch, Plr.e
Crawford & Company
(Hr. Brown, Claim Atijufltel')
(Ft. Florce orrico)
Ft,. Pierco, Florida
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Sub50rlbad and sworn to
bofore me this 15th diiY
of february, 19&2
\n10S0 bualno3o addross in:
/J''; I' I " .r 1)00 No!,th D1Jd_o H1.f:hwB.Y
. <I',I aJ;.~).~A_/ ::V!s:.C~~2:~---we8t Palm Boachi Plorida
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~ IIJ 00,.,,1..10n oxp1re.'
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Mall address:
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: ~~ Off~f.' Ret:ori...- t - I ~
1%2 FEE! 1 r.~ II: 35
P. o. DOJ: 28Y1
W6st Palm iloa{\h~ F'la..
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